Clinical characteristics of psychotic disorders in patients with childhood trauma

Childhood trauma is an important predictor of psychotic disorders, with special emphasis on physical and sexual abuse. It influences the clinical picture and course of psychotic disorders. This study was conducted in the Department of Psychiatry of the University Clinical Hospital Mostar. The sample consisted of 135 participants, aged 18 to 65 years. The screening instrument to examine cognitive status was the short version of MMSE-2. Patients’ background information was collected using a sociodemographic questionnaire constructed for this study. To determine childhood trauma, the Child Abuse Experience Inventory was used to examine physical, sexual, and emotional abuse, neglect and domestic violence. The positive and negative syndrome scale scale was used to evaluate the clinical profile of psychoticism, the SSI questionnaire was used to evaluate the severity of suicidality, and the functionality of the participants was evaluated using the WHODAS 2.0. Results indicate that a significant number of participants with psychotic disorders experienced childhood trauma, an important determinant of their illness. Participants who had witnessed abuse had more severe clinical presentations (earlier onset and longer duration of illness) and more pronounced psychotic symptomatology and a lower degree of functionality. Decreased functionality is associated with witnessing abuse and physical abuse. During the civil war, a significant percentage of the participants were in childhood and adolescent development (26.7%) and exposed to frequent emotional abuse and domestic violence. As 1 traumatic event in childhood makes a person more susceptible to more traumatic experiences during life. Childhood trauma is a serious and pervasive problem that has a significant impact on the development, course, and severity of the clinical presentation of psychotic disorders. Accordingly, it is necessary to provide continuous education to mental health workers, primarily psychiatrists, regarding childhood trauma so that treatment may be approached more systematically and a plan of therapeutic interventions may be more adequately designed, which would necessarily include psychosocial support in addition to pharmacotherapy.


Introduction
[3] One third of the general population experiences some form of childhood trauma during lifetime. [4,5][15][16][17][18] According to the literature, the risk of developing psychosis is 2 to 3 times higher in people who have experienced childhood trauma than in people who have not. [19,20]In accordance with this, numerous studies have established a high frequency of childhood trauma in people with schizophrenia. [6,21,22]n addition to the fact that childhood trauma is associated with an increased risk of psychotic disorder development, it is also often considered an important determinant of psychotic symptomatology in adulthood. [3,23,24][27] Other studies link neglect in childhood with the development of persecutory delusions and negative symptomatology. [7,22,28,29]][32] For example, psychotic patients who experienced childhood adversities have a higher rate of suicidal thoughts and suicides compared with patients without those traumatic experiences. [3,33]In addition, other studies have shown that patients with psychosis who experienced childhood trauma have lower pre-morbid functioning, earlier onset of psychosis, less effective treatment outcomes in terms of chronicity and recurrent episodes of illness, and lower rates of compliance. [5,29,33]onsidering the level and complexity of prolonged individual and social traumatization in war-affected Bosnia and Herzegovina, [34] it is assumed that war trauma in people with psychosis will have an impact on the clinical characteristics and course of their illness.37][38] This study aimed to determine the relationship between childhood trauma and clinical characteristics of psychotic disorders.

Participants and methods
This cross-sectional study was conducted in the Department of Psychiatry of the University Hospital Mostar in the period from January to October 2022.All patients aged 18 to 65 years who were hospitalized in the above-mentioned Department of Psychiatry due to any type of psychotic disorder (acute psychotic disorder, schizophrenia, schizoaffective disorder, unspecified psychosis or affective disorders with psychotic symptoms) were included.Diagnoses were made based on the International Classification of Diseases 10th Revision criteria by a team of experienced clinicians, psychiatrists and psychologists, with a minimum of 10 years of clinical work in the Department of Psychiatry.Psychiatrists ascertained the diagnosis by psychiatric interview and clinical picture upon admission.41][42][43] Participants were included in the order of appearance from the day the study began, until a sample of 135 patients with psychosis was formed.All the participants were informed of the study by the principal investigator.Those who agreed to participate signed the Informed Consent form.In cases in which a participant was deemed incompetent, informed consent was signed by their legal guardian.Ethics approval was provided by Ethical Committee of Medical school of the University of Mostar (Protocol number 01-1-559/17).
After the participants signed the informed consent, the Mini Mental State Examination, short version questionnaire (Mini Mental State Examination-short version) was administered to evaluate their cognitive status, and the total score was used as the inclusion/exclusion criteria in the study.In this phase, 25 (15.6%)participants were excluded.The participants were then given a battery of tests consisting of self-assessment scales (Child Abuse Experience Inventory), SSI (scale of suicidal ideation) and WHODAS 2.0 (World Health Organization Disability Assessment Schedule) along with a sociodemographic questionnaire that they filled in the presence of the main researcher, and the PANSS (positive and negative syndrome scale) questionnaire filled out by the main researcher.

Instruments of the study
For this study, a sociodemographic questionnaire was constructed to collect patient background information.In addition to general sociodemographic data, the questionnaire also contained data on the onset and course of mental illness and number of previous hospitalizations.
A short version of the Mini Mental State Examination, short version questionnaire, used for clinical and research purposes, was utilized as a screening instrument to examine the cognitive status of the participants. [44]This questionnaire contains 16 items where every correct answer was scored with 1 point and the total score was the sum of all the correct answers.Participants with a total score of <13 points were considered to have significant cognitive impairment and were excluded from the study.
To determine childhood trauma, the Child Abuse Experience Inventory was used to examine physical, sexual, and emotional abuse, neglect and domestic violence.The results were expressed as the sum of participants' answers, especially for physical, emotional and sexual abuse and neglect, and at the level of the entire instrument, where a higher score indicated a higher prevalence of certain forms of abuse, which means a higher prevalence of trauma in childhood. [45]he PANSS, which is widely used in research on patients with psychosis, was used to evaluate the clinical profile of psychoticism.It consists of 30 items divided into 3 subscales: positive symptoms, negative symptoms, and general psychopathology.Responses were recorded on a Likert scale from 1 to 7, where a higher number indicated more pronounced symptomatology. [46]he SSI questionnaire was used to evaluate the severity of the suicidality.It is a semi-structured interview that evaluates 3 dimensions of suicidal ideation: active suicidal desire, the existence of plans to commit suicide, and passive suicidal desire.The higher the total score, the more serious is the suicidal ideation. [47]he functionality of the participants was evaluated using the WHODAS 2.0.This questionnaire assessed the level of functionality in 6 areas: understanding and communication, mobility, self-care, interacting with other people, life activities, and participation in community activities.Higher scores indicated a higher level of disability in each examined area and at the level of the entire instrument. [48]

Statistical analysis
Statistical analysis was performed using SPSS software (version 25.0; IBM, Armonk, NY).Descriptive statistics were applied to analyze social demographic data and results on Child Abuse Experience Inventory.The continuous data were described as the mean ± SD.The categorical data were described as N (%).A Spearmans correlation analysis was performed to evaluate the independent correlation between different types of childhood abuse (for non-normal distributed data determined using Kolmogorov-Smirnov test).
Hierarchical multiple regression analysis was conducted to explore the association between traumatization and functionality and psychotic symptomatology.Potential predictors with high co-variability (R > 0.7) were excluded from the model to reduce over-parameterization (psychological abuse).
The variance inflation factor was <10, which suggested there was no collinearity between variables.The contribution of predictor variables regarding childhood trauma to the explanation of psychotic disorders onset, was verified using ordinal regression analysis.The probability level of P < .05 was taken as statistically significant. [49] Results

Sociodemographic data
This study included 135 participants who were diagnosed with a psychotic disorder, among whom 80 (59.1%) were male, and 55 (42.7%) were female.The average age of the participants was 37 years (SD = 11.94).The majority, (93.3%), grew up in a complete family, and 6.7% lived in an incomplete family.The other sociodemographic data and basic descriptive parameters of the Child Abuse Experience Inventory (where higher results represented greater exposure to abuse throughout childhood) are summarized in Table 1.
A significant positive correlation was established between different types of abuse (r s = 0.396-0.905,P < ..001): participants who were more often exposed to 1 type of abuse during childhood, were more often exposed to other types of abuse, or had witnessed abuse more often.

Impact of childhood trauma and participation in war, exile and divorce of parents on the onset of psychotic disorders
The contribution of predictor variables regarding childhood trauma, sociodemographic variables (age and divorce of parents), participation in war and exile to the explanation of psychotic disorder onset, were verified using an ordinal regression analysis (Table 2).The selected set of predictors explained approximately 32.6% (r2 Naglkerkea) of the variance in the results related to the onset of psychotic disorders, of which age and witnessing abuse significantly contributed to the explanation of the criterion variable.Participants who are now older, as expected, had earlier onset of psychotic disorder and longer duration of illness, as well as those who witnesses abuse in childhood.

Impact of childhood trauma and participation in war, exile and divorce of parents on functionality of psychotic patients
Table 3 displays the results of the hierarchical multiple regression analysis where childhood abuse (Model 1) was significant and accounted for 7.9% of the variance in the WHODAS results.In Model 2, inserting participation in war, exile and divorce of parents led to an increase of 2.5% in the variance explained compared to Step 1 (for a total of 10.4%).In this analysis, witnessing abuse and physical abuse were found to be significant influencing factors.A higher level of witnessing abuse in childhood and a lower level of physical abuse are associated with a higher result on the WHODAS questionnaire which indicates lower functionality of psychotic patients or higher levels of disability in psychotic patients.

Impact of childhood traumatization, participation in war, age, exile and divorce of parents on severity of clinical presentation psychotic disorders
Table 4 displays the results of the hierarchical multiple regression analysis where childhood abuse (Model 1) accounted for 8.1% of the variance in the PANSS results.In Model 2, inserting participation in war, age, exile and divorce of parents led to an increase of 13% in the variance explained compared to Step 1 (for a total of 21.1%).Age and witnessing abuse were significant influencing factors-participants who were younger and witnessed abuse had more pronounced psychotic symptomatology.
The Impact of childhood trauma, age, participation in war, exile and parental divorce on suicidal ideation (SSI) was determined using hierarchical multiple regression analysis and it was found that the overall model was not statistically significant (R 2 = 0.091, F = 1.387, df = 9, P = .201).

Association between childhood trauma, functionality and clinical presentation of psychotic disorder
Examining the relationship between the incidence and type of childhood trauma with severity of clinical presentation shown  through the results of the PANSS questionnaire using Spearman correlation, demonstrated that there is a positive and weak association between general psychopathology on PANSS and all types of childhood traumatization (r s = 0.188 (P < .05)-0.312 (P < .001)),as well as between positive symptoms and sexual abuse (r s = 0.195, P < .05),negative symptoms and sexual abuse (r s = 0.190, P < .05)and neglect (r s = 0.177, P < .05).

Discussion
The results of this study indicate that a significant number of people with psychotic disorders experienced some form of childhood trauma, and that childhood trauma is a significant determinant of their illness.Individuals with psychotic disorders who had experienced childhood trauma and participated in war had more severe clinical presentations and lower degrees of functionality.These findings are in agreement with other studies that have shown that childhood trauma is an important predictor of worse treatment outcomes, lower compliance rates and reduced social functioning in patients with psychotic and non-psychotic mental disorders. [3,5,9,30,50,51]The same can be connected with the high degree of individual and systemic traumatization that the parents of the participants experienced during the 5-year period of the civil war that was held in this area 3 decades ago. [34]t should be noted that a significant percentage of the participants in this study, during the period of war, were in childhood and adolescent development (26.7%) and were presumably exposed to frequent emotional abuse and often witnessed domestic violence.Previous studies are clear in their findings that dysfunctionality is more often present in war traumatized families, as well as all forms of family violence. [52,53]Young people who went to war, escaping from such unfavorable family and social systems, and having experienced a series of traumatic experiences in the war, increased the risk of developing psychotic disorders according to the principle of the cumulative effect of trauma. [3,54,55]he severity of clinical presentation assessed using the PANSS questionnaire indicated that the age and witnessing abuse are significant influencing factor in emergence of psychotic disorder: younger participants and those who witnessed abuse had more pronounced psychotic symptomatology.[58] Trauma in childhood of high intensity, makes a person in adulthood more susceptible to more intense responses to stress and the development of psychological distress. [3,20,59]A significant positive correlation between different types of abuse was found in this study, which means that participants who were more often exposed to 1 type of abuse in childhood were more often exposed to other types of abuse or had witnessed abuse more often (This result is presented in Supplemental Digital Content, Table 1, http://links.lww.com/MD/L117).Moreover, traumatogenic neurodevelopmental model is based on this concept. [3]The weak association between childhood traumatization and clinical representation of psychotic disorders indicates the existence of certain associations, but also the need for further examination of the characteristics of that association and the need to consider other relevant factors that can influence the severity of the clinical picture of psychotic disorders.
The clinical course of illness was evaluated based on the suicidality and degree of functionality.Decreased functionality in individuals with psychosis is associated with witnessing abuse.[62][63] Furthermore, other studies have pointed out that active or passive participation in war was found to have a significantly negative effect on mental health and overall functioning. [37,64]Given that relationships in early childhood are key to the establishment of healthy interpersonal relationships throughout life, disturbed harmony of relationships in primary families results in difficulties in later interpersonal relationships. [22,30,65]We should certainly not ignore the impaired family support in treatment and life, which apparently war-traumatized and dysfunctional families were not able to provide their members with mental disorders. [34,66]This finding is consistent with the results of other studies', which found that patients who lack social support will have poorer disease control in the form of irregularly taking the prescribed therapy and irregularly going to the psychiatrist checkups. [57,63,67]Childhood trauma represents an additional burden on top of the already existing series of unfavorable life factors, such as reduced social network, lack of social support, lack of functionality in everyday activities, a more severe clinical  presentation, the existence of psychiatric comorbidities, unemployment and a single lifestyle.This study had several limitations, the most important of which were the size and structure of the sample.As emphasized earlier, the sample is convenient and, as such, is certainly a less ideal choice than any probabilistic sample.Bonferroni correction was not performed for the comparisons in our study.There is, however, some debate in this regard, as it can increase type II error, cause significant differences to be considered insignificant, reduce statistical power, and cause bias.Therefore, publications are suggesting that Bonferroni correction should not be done, and it is not conducted in this study. [68]he metric limitation is the nonexistence of a single criterion for determining the incidence of experienced abuse, that is, the determination of a threshold score, that does not enable the exact degree of exposure to traumatic events in an individual.Therefore, it is not possible to determine the exact number of participants with childhood trauma, but only the frequency of its occurrence.The study was conducted transversally and the most of the collected data were based on the participants' self-reporting.
It is important to note that that the main focus of this study was to examine the relationship between childhood trauma and psychotic disorders, and bivariate correlations, among other analysis, showed significant, but weak correlations among the examined variables (presented in Supplemental Digital Content).As this approach showed a possible correlation between examined variables it is worth mentioning that it is necessary for future studies to try to identify the exact variable that has the most impact on developing psychotic disorders in order to define more precisely the relationship between traumatic experiences and the onset of psychosis.
We conclude that childhood trauma is a serious and pervasive problem that has a significant impact on the development, course, and severity of the clinical presentation of psychotic disorders.The importance of childhood trauma directly influences a more comprehensive understanding of the mechanism of psychosis development and contributes to an understanding of the social aspect of the emergence of psychotic disorders.Accordingly, it is necessary to provide continuous education to mental health workers, primarily psychiatrists, regarding childhood trauma, so that treatment may be approached more systematically and a plan of therapeutic interventions may be more adequately designed, which would necessarily include psychosocial support in addition to pharmacotherapy.

Table 1
Baseline characteristics of study participants and basic descriptive parameters of results on Child Abuse Experience Inventory.
Data are expressed as mean and standard deviation.Qualitative variables are presented as frequency and percentage.

Table 2
Results of ordinal logistic regression analysis for onset of psychotic disorder.

Table 3
Hierarchical multiple regression analysis results for level of functionality psychotic patients expressed through the result on the WHODAS 2.0.

Table 4
Hierarchical multiple regression analysis results for psychotic symptomatology expressed through the result on PANSS.